Ross grief stages about living well with Dysautonomia? Morwenna - PowerPoint PPT Presentation

What we can learn from the Kubler- Ross grief stages about living well with Dysautonomia? Morwenna Opie, PhD, DipClinPsych

Aims • Shed some light on the emotional rollercoaster that is loss associated with chronic illness • Suggest why particular strategies and interventions from CBT are especially relevant at different parts of that ride • Make clear the importance of acceptance in living well 2

It will not... • Suggest psychological processes cause dysautonomia • Suggest everyone responds to loss or ill health in the same way 3

Why a grief model? • Illness is undoubtedly loss – self, immortality, and envisioned future, • Helps explain why psychological support is relevant • Helps explain what might be relevant when • Encourages self- compassion and understanding and hope • Permission to grieve 4

Why a K-R grief model? • Normalises a common • If it is good enough for but highly individual and House... challenging experience and associated complex emotions • A reminder that loss and adjustment is not binary • Has good face validity and is helpful for targeting intervention 5

Examples of thoughts at each stage • DENIAL - “They are wrong” “This will pass” “I don’t need to change” • ANGER - “Why me” “Why not you” “It is all their fault” “I hate this and a world that did this to me” • BARGAINGING – “ I will never say another mean word if I can just be better” “Just let me do this one more test/ try one more treatment and I will do anything” • DEPRESSION – “My situation and my future is bleak” “I don’t know who I am anymore” • ACCEPTANCE - “ I don’t like this, but I can still live well and find meaning and joy in life.” “I can balance time dedicated to looking after and improving my health – with still living and loving life with it in the meantime.” 6

The Model • The 5 stages of grief by Swiss psychiatrist Kubler-Ross On death and dying (1969) – expanded to include other loss including rejection and chronic illness • Not uncriticised. She herself first to acknowledge that the model not complete and individuals do not progress through stages • Baxter Jennings, University of Kentucky, 2012 – inadequate consideration of the personal environment – social support and engagement in positive experiences as a very important mediating factor • McDougall – maximise skills and knowledge and celebrate ongoing personal uniqueness • Legacy – discussing feelings candidly and courageously as beneficial to outcome 7

Why CBT? • CBT has a good empirical basis in helping navigate grief and also • protecting against developing more serious mental-health difficulties 8

Put simply, CBT is... • The way we feel isn’t directly determined by what life throws at us, but is mediated by our environment, our physiological responses, and also how we think about/evaluate it ( our cognitions ) and what we do as a result ( our behaviours ) • If we can gain some control over the latter two, we can ultimately have some choice about how we feel. 9

Put even more simply, CBT is... • CBT is about how to be as good a friend to ourselves as we generally are to others 10

Flags and signposting • Examine each of the 5 stages of loss in the K-R model • Consider the psychological processes involved • Consider ways to support yourself or a loved one at each phase (and perhaps what not to attempt) • NB All emotions are legitimate and understandable (or else we tell ourselves we are somehow unacceptable with consequences for self-esteem and self-trust) – but we can consider them a flag to consider rather than an emotional/behavioural inevitability 11

1). Shock and Denial • “They are wrong” “This will pass” “I don’t need to change ” • Reckless or uncharacteristic behaviours • Emotions numbed 12

1). Shock and/or denial • Process of emotional protection, numbing, which can allow time to process manageably • Problematic when: Important lifestyle advice and health- related behaviours are ignored e.g. failing to pace, medicate or to self-sooth, & withdrawal. • Useful strategies for shock/denial: 5 senses soothing, memory box, getting informed, company, establishing simple routines, TIME, rest 13

• Example of a memory/hope box 14

2). Anger • “Why me” “Why not you” “It is all their fault” “I hate this and a world that did this to me ” • Aggressive behaviours • Externalised emotional expression 15

2). Anger • Primary emotions often emerge before more complex emotions surface. Expression can be cathartic and allow more complex cognitive processes to follow and be worked through • Problematic when: – a). misdirected and causes further loss as a result (friends, loved ones, medics) – b). anger is arousal, fight/flight, an inflammatory process counter to healing and which can exacerbate symptoms of dysautonomia • Useful strategies for anger – To recognise it is justified is not the same as feeling it must be fuelled – Discreet safe cathartic activities (smashing things, noise etc) and exercise – Self-soothing - 5 senses, breathing, relaxation 16

All-senses soothing strategy for strong emotions including anger • SELF-SOOTHING has to do with comforting, nurturing and being kind to yourself. One way to think of this is to think of ways of putting together an activity plan/package which soothes each of your five senses: • VISION : Look at the nature around you. Go to a museum with beautiful art. Buy a flower and put it where you can see it. Sit in a garden. Watch the snowflakes decorate the trees during a snowfall. Light a candle and watch the flame. Look at a book with beautiful scenery or beautiful art. Watch a travel movie or video. HEARING : Listen to beautiful or soothing music, or to tapes of the ocean or other sounds of nature. Listen to a baby gurgling or a small animal. Sit by a waterfall. Listen to someone chopping wood. When you are listening, be mindful, letting the sounds come and go. SMELL : Smell breakfast being cooked at home or in a restaurant. Notice all the different smells around you. Walk in a garden or in the woods, maybe just after a rain, and breathe in the smells of nature. Light a scented candle or incense. Bake some bread or a cake, and take in all the smells. TASTE : Have a special treat, and eat it slowly, savouring each bite. Cook a favourite meal. Drink a soothing drink like herbal tea or hot chocolate. Let the taste run over your tongue and slowly down your throat. Go to a potluck, and eat a little bit of each dish, mindfully tasting each new thing. TOUCH: Take a bubble bath. Pet your dog or cat or cuddle a baby. Put on a silk shirt or blouse, and feel its softness and smoothness, or a favourite persons sweater. Sink into a really comfortable bed. Float or swim in a pool, play with playdough 17

Humour, the great anger diffuser 18

We have all been here... 19

3). Bargaining • “ I will never say another mean word if I can just be better” “Just let me do this one more test/ try one more treatment and I will do/give anything ” • Can be prone to desperate acts and illogical behaviours • Emotions can be chaotically directed 20

3). Bargaining • Attempt to gain some control over the situation (i.e. get rid of all pain and symptoms and distress) • Problematic when : magical thinking becomes obsessive or obstructive to positive planning and adaptation • Useful strategies for bargaining • Use this energy to begin engaging in healthy choices and becoming responsible TO (not for) the illness • Hope • Meditation to step back to notice and defuse magical thoughts and increase psychological flexibility • e.g. replace buts with ands & tolerating not running from pain and difficulty 21

Meditation • Meditation - benefits wide ranging in health, including bp, cancer progression, even blood-sugar regulation in diabetes) 22

Meditation cont. 23

4). Depression • “My situation and my future is bleak” “I don’t know who I am anymore ” • Withdrawal, lack of self-care • Internalised emotion 24

4). Reactive depression • Very present and deep grief and sadness in reaction to loss. Not indicative of mental illness, but an appropriate response to loss and concern for the future. Associated with anxiety/disinterest in future • Problematic when incapacitating, hope disappears, isolation • Useful strategies for reactive depression • Paced behavioural activation • Cognitive work restoring more balanced thinking • Typical thinking errors from those experiencing loss – grey glasses including 25

Reactive depression 26

5). Acceptance • “ I don’t like this, but I can still live well and find meaning and joy in life .” • Healthy balanced behaviours (challenges and recuperation) • Emotions channelled productively 27